Overview
Low awareness of the symptoms of any health condition is a huge barrier to receiving effective treatment. People with bipolar disorder often experience a lack of insight into their mental state, particularly during a manic episode.
Anosognosia (difficulty recognising and acknowledging a health condition) can therefore prevent people with bipolar disorder from being able to independently access the support that they need. It can also make it difficult to independently keep to treatment plans that help them maintain mental well-being.
Awareness of anosognosia is also important for professionals and loved ones who support people with bipolar, as the person may struggle to accept support if they don’t believe that they need it.
This article explains what you need to know about anosognosia, how it affects people with bipolar, and how you or your loved one can access relevant support.
Bipolar disorder – what is it?
Bipolar Disorder is a mood disorder that causes periods of change in a person's energy, activity levels, and concentration. These variations can feel very extreme or distressing, and make it challenging to carry out day-to-day tasks. The moods can swing from manic episodes (extremely excited or irritable periods) to depressive episodes (very sad or indifferent or hopeless periods), and hypomanic episodes, which is the less severe form of a manic episode. About 40 million people across the world have bipolar disorder (previously known as manic depression). Although the condition is thought to affect the genders equally, more women are diagnosed. People with bipolar disorder may receive a diagnosis of Bipolar 1, Bipolar 2, or cyclothymia. Other subtypes of bipolar disorder include rapid cycling bipolar, bipolar disorder with a seasonal pattern, unspecified bipolar, or bipolar with mixed features.
Anosognosia – what is it?
“Anosognosia'' (pronounced as uh-no-sog-noh-zee-uh) is a Greek word which translates as “not know a disease”. It is a neuropsychiatric condition that affects people with severe mental illness and neurological disorders. Individuals affected by anosognosia do not realise that they are mentally ill. They are unable to recognise the signs, symptoms, and implications of their diagnosis and so they believe that they are not unwell and do not need treatment.2 Anosognosia affects 40% of patients with bipolar disorder.3 Its presentation varies from complete refusal to believe that bipolar disorder exists and non-acceptance of their diagnosis, to downplaying and justifying their symptoms. This can include disputing the benefits of taking prescribed medication.4
Studies suggest that people with bipolar disorder are mostly affected by anosognosia during manic episodes.5 Anosognosia is most severe in phases of acute mania and less severe during periods of bipolar depression. It is important to note that anosognosia occurs more frequently in depression associated with psychosis than in non-psychotic clinical depression. Anosognosia also seems to get better upon acute recovery from psychotic depression.6 There are mixed findings about whether psychosis affects the level of insight in patients with bipolar disorder. Some studies have shown that patients who have bipolar disorder alongside psychosis tend to show less insight into their illness than those without psychosis.7 However, other studies indicate that psychosis did not affect the level of insight in people experiencing mania.8
In bipolar disorder, anosognosia has been linked to the number of times a patient experienced manic episodes. For those who only had one manic episode, insight was normal before the manic episode. However, individuals who experienced several manic episodes did not typically see improved insight before and after subsequent episodes. Interestingly, the level of insight during depressive episodes does not seem to be affected by the number of depressive episodes experienced.7
Impact of anosognosia on bipolar disorder
Anosognosia can affect many different aspects of bipolar disorder. Some examples include:
Difficulty following treatment plans, medication regimes, and keeping appointments. Anosognosia in bipolar disorder appears to be the most important factor affecting compliance with treatment and follow-up appointments. This may be unintentional, due to difficulties in remembering or intentional, because the person does not believe that they are unwell and need treatment.9,10,11,12
- Struggling to accept that they need to take medication. Some people experiencing anosognosia may also believe that the medication could harm them. (For example, because of the side effects). As a result, they may reduce or stop taking prescribed medication.
- Increased episodes of being unwell, possibly leading to hospitalisation, because of the reduced effectiveness of medication if it is not taken as prescribed.13 However, good awareness of bipolar disorder helps to improve compliance with treatment and enables a good therapeutic relationship to develop through regular attendance to appointments. This benefits the person’s overall health.14
- Dissatisfaction with quality of life. People with bipolar disorder often experience this even during periods of more stable mental health.15,16
Causes of anosognosia in mental health conditions
The exact cause of anosognosia is unknown. However, it could be due to structural and functional damage to specific areas of the brain, including:2,17,18
- The prefrontal cortex: is responsible for regulating our thoughts, actions, and emotions by extensively connecting with other parts of the brain. Functions of the prefrontal cortex include empathy, insight, response flexibility, emotion and body regulation, morality, intuition, attuned communication, and modulation of fear. A dysfunction in the prefrontal cortex can lead to forgetfulness, poor concentration, disorganization, reduced insight, judgment, moral conscience, concrete thinking decreased empathy, compassion, optimism, persistence, and self-regulation.
- Insula cortex: responsible for the sensing of different body states such as pain, hunger, nausea, and being tickled. The insula cortex is connected to emotions such as joy, anger, hatred, empathy, and compassion. It is also involved in cognitive function, interindividual relationships, and regulating the body's homeostasis.
- Default mode network: the connection between the prefrontal cortex, parietal cortex, and cingulate cortex.
Assessment of anosognosia
Over the years, different assessment scales have been developed to measure the level of anosognosia in patients. However, the Scale to Assess Unawareness of Mental Disorder (SUMD) developed by Amador and Strauss has been widely accepted and validated as a pluridimensional measurement of insight. This scale differentiates present and past levels of consciousness of having a mental disorder, the effects of medication, the implications of mental disorders, and the distinctive signs and symptoms.
This assessment is carried out by a doctor or a trained reviewer and can last up to 40 minutes. A five-level Likert scale is used, with a value of zero indicating complete insight.19 If you feel that you or a loved one are experiencing anosognosia as part of bipolar disorder or another mental health condition, you can ask for assessment and feedback from your primary care provider (such as a GP or MD). Or you can ask a mental health professional who you are working with.
Summary
Anosognosia is a condition where a person is unaware of their symptoms and the seriousness of their illness. It affects about 40% of individuals with bipolar disorder.
During manic episodes, the lack of awareness is particularly severe compared to depressive episodes. This lack of awareness is why some patients with bipolar disorder do not seek help from health professionals and may not follow their prescribed treatment. This can lead to their treatment for bipolar disorder not being effective and may mean that they experience frequent relapses.
Increased awareness of anosognosia, and guidance on how to support someone who experiences this, can help to improve access to treatment and avoidance of bipolar relapses.
References
- Bipolar Disorder - National Institute of Mental Health (NIMH) [Internet]. [cited 2024 Apr 26]. Available from: https://www.nimh.nih.gov/health/topics/bipolar-disorder
- Acharya AB, Sánchez-Manso JC. Anosognosia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK513361/.
- Fennig S, Everett E, Bromet EJ, Jandorf L, Fennig SR, Tanenberg-Karant M, Craig TJ. Insight in first-admission psychotic patients. Schizophr Res. 1996 Dec 15;22(3):257-63. [PubMed]
- Crișan CA. Lack of Insight in Bipolar Disorder: The Impact on Treatment Adherence, Adverse Clinical Outcomes and Quality of Life. In: Durbano F, editor. Psychotic Disorders - An Update [Internet]. InTech; 2018 [cited 2024 Apr 26]. Available from: http://www.intechopen.com/books/psychotic-disorders-an-update/lack-of-insight-in-bipolar-disorder-the-impact-on-treatment-adherence-adverse-clinical-outcomes-and-
- Olaya B, Marsà F, Ochoa S, Balanzá-Martínez V, Barbeito S, García-Portilla MP, et al. Development of the insight scale for affective disorders (ISAD): Modification from the scale to assess unawareness of mental disorder. Journal of Affective Disorders [Internet]. 2012 [cited 2024 Apr 26]; 142(1–3):65–71. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165032712002418
- Amador XF. Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders. Arch Gen Psychiatry [Internet]. 1994 [cited 2024 Apr 26]; 51(10):826. Available from: http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.1994.03950100074007.
- Yen C, Chen C, Cheng C, Yen C, Lin H, Ko C, et al. Comparisons of insight in schizophrenia, bipolar I disorder, and depressive disorders with and without comorbid alcohol use disorder. Psychiatry Clin Neurosci [Internet]. 2008 [cited 2024 Apr 26]; 62(6):685–90. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1819.2008.01870.x.
- Peralta V, Cuesta MJ. Lack of insight in mood disorders. J Affect Disord. 1998 Apr;49(1):55-8. doi: 10.1016/s0165-0327(97)00198-5. PMID: 9574860.
- Buckley PF, Wirshing DA, Bhushan P, Pierre JM, Resnick SA, Wirshing WC. Lack of Insight in Schizophrenia: Impact on Treatment Adherence. CNS Drugs [Internet]. 2007 [cited 2024 Apr 26]; 21(2):129–41. Available from: http://link.springer.com/10.2165/00023210-200721020-00004
- Lingam R, Scott J. Treatment non‐adherence in affective disorders. Acta Psychiatr Scand [Internet]. 2002 [cited 2024 Apr 26]; 105(3):164–72. Available from: https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0447.2002.1r084.x.
- Maurino J, Montes, De Dios C, Medina. Suboptimal treatment adherence in bipolar disorder: impact on clinical outcomes and functioning. PPA [Internet]. 2013 [cited 2024 Apr 26]; 89. Available from: http://www.dovepress.com/suboptimal-treatment-adherence-in-bipolar-disorder-impact-on-clinical--peer-reviewed-article-PPA.
- Leclerc E, Mansur RB, Brietzke E. Determinants of adherence to treatment in bipolar disorder: A comprehensive review. Journal of Affective Disorders [Internet]. 2013 [cited 2024 Apr 26]; 149(1–3):247–52. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165032713000918.
- Jeste SD, Patterson TL, Palmer BW, Dolder CR, Goldman S, Jeste DV. Cognitive predictors of medication adherence among middle-aged and older outpatients with schizophrenia. Schizophrenia Research [Internet]. 2003 [cited 2024 Apr 26]; 63(1–2):49–58. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0920996402003146.
- Novick D, Montgomery W, Treuer T, Aguado J, Kraemer S, Haro JM. Relationship of insight with medication adherence and the impact on outcomes in patients with schizophrenia and bipolar disorder: results from a 1-year European outpatient observational study. BMC Psychiatry [Internet]. 2015 [cited 2024 Apr 26]; 15(1):189. Available from: http://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-015-0560-4.
- Dias VV, Brissos S, Frey BN, Kapczinski F. Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder. Journal of Affective Disorders [Internet]. 2008 [cited 2024 Apr 26]; 110(1–2):75–83. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165032708000311.
- Yen C, Cheng C, Huang C, Yen J, Ko C, Chen C. Quality of life and its association with insight, adverse effects of medication and use of atypical antipsychotics in patients with bipolar disorder and schizophrenia in remission. Bipolar Disorders [Internet]. 2008 [cited 2024 Apr 26]; 10(5):617–24. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1399-5618.2007.00577.x.
- Arnsten AFT. Stress signalling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci [Internet]. 2009 [cited 2024 Apr 26]; 10(6):410–22. Available from: https://www.nature.com/articles/nrn2648.
- Arnsten AFT, Shanafelt T. Physician Distress and Burnout: The Neurobiological Perspective. Mayo Clinic Proceedings [Internet]. 2021 [cited 2024 Apr 26]; 96(3):763–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0025619620315007.
- Assessment of insight in psychosis. AJP [Internet]. 1993 [cited 2024 Apr 26]; 150(6):873–9. Available from: http://psychiatryonline.org/doi/abs/10.1176/ajp.150.6.873.